Markers for side complications among diabetic mellitus patients

People's Democratic Republic of Algeria

Ministry of Higher Education and Scientific Research

Mentouri University Constantine Faculty of Natural Sciences and Life Department of Natural Sciences and Life

N° d’ordre N° de série

Markers for side complications among diabetic mellitus patients

Submitted for the degree of Doctorat d'état in Animal Biology and Physiology

Thesis presented by

Salah Attalah

Approval Sheet

President Prof. Zahia MERAIHI (University of Mentouri, Constantine) Supervisor Prof. Ahmed M. IBRAHIM (National Research Centre, Egypt) Co-Supervisor Prof. Cherifa BENLETRECHE (CHU Ibn Badis, Constantine)

Examiner Dr. Aicha MECHAKRA (University of Mentouri, Constantine) Examiner Prof. Cherif ABDENNOUR (University of Badji Mokhtar, Annaba)

Examiner Prof. Saad SAKA (University of Badji Mokhtar, Annaba)

Acknowledgments

First, my gratitude and thanks should be submitted to "THE GOD" for his kind support witch is in every success in my life.

I wish to express my deepest thanks and gratitude to the late Prof.

Mohamed Fathi El-Howary, Prof. of Biochemistry, National Research Centre, for suggesting the topic of this work.

I wish to express my sincere thanks and gratitude to Prof. Ahmed Mohamed Ibrahim, Prof. of Biochemistry, National Research Centre, for his continuous advice, sincere supervisions help and encouragement throughout the practical work and during the writing of the manuscript.

I wish to express my profoundly gratitude to Prof. Ben Latreche Chrifa, Prof of Biochemistry , Hospital Centre University, Laboratory of Biochemistry , Ibn Badiss, Constantine, Algeria, for her kind supervision, guidance, continuous advice, help and encouragement throughout the practical work.

I wish to express my deepest thanks and gratitude to Dr. Mamdouh AIi, Ass, Prof. of Biochemistry, National Research Centre, for his support and for his sincere help and encouragement, and sincere advices.

I am greatly indebted and grateful to Prof Abdelmohsen Saber Isamail, Prof. of Biochemistry, National Research Centre, for his encouragement, and sincere advices.

Deepest gratitude is indebted to the National Research Centre, and the Institute of Diabetes, Ministry of Heath, Cairo, for the facilities that enabled me to do this work.

Last but not least, I wish to express my deep gratitude to my wife for her sacrifice and immolation, also for her constant help and sincere encouragement, am really indebted for her. Also, I express my deep gratitude to my parents and all family for the excellent efforts through the thesis preparation.

Lastly, I am grateful to all patients who shared in this study to whom I am

greatly indebted.

carbohydrate, lipids, proteins and enzymes activities. The purpose of this study is to determine if the pancreatic or liver and kidney function tests are changed in diabetic patients with or without ketosis and whether ketosis show any evidence of pancreatitis in juvenile or adult diabetic patients. For this reason three groups of diabetic patients associated with either ketotic or non-ketotic condition were selected and investigated.

60 diabetic patients were chosen for investigations on liver and pancreatic function tests for serum GOT, GPT, ALP, lipase, and amylase enzymes. Kidney function tests were also assed for blood urea, and serum creatinine. Serum total protein and protein fractions were also studied. In addition, correlation of such finding with age, sex, ketotic state and type of diabetics have been investigated.

Although many biochemical parameters are now available, investigations of diabetic patients with pancreatic disease, yet any one of them alone was found unsatisfactory.

From our data, we concluded, the increased lipase and amylase activities are good indicators for the diagnostic of tissue injury (pancreatitis), particularly in juvenile diabetic patients associated with ketosis as compared to diabetic patients without ketosis.

Other 85 diabetic patients were also chosen for serum total lipids, triglycerides, free fatty acids, cholesterol and phospholipids. In all diabetics, the mean value of serum total lipids was significantly increased as compared to the control. In both ketotic and non-ketotic females, the level of serum cholesterol was significantly increased while in males the level was insignificantly increased as compared to control. Furthermore, serum triglyceride level was significantly increased in both sexes of the ketotic than in the non-ketotic and the control.

In both sexes the serum triglyceride level, which showed high value in poorly-controlled patients, revealed normal value with the proper control of blood glucose level by insulin treatment. Thus, our results showed increased level of free fatty acids in all groups as compared to the corresponding control.

Also, we concluded that the elevation of individual lipid components is very important to be analyzed regularly in order to follow the modulation of risk condition in diabetic patients.

A great interest, also, to follow up the abnormal lipid metabolism to avoid any metabolic complication.

115 Juvenile and adult diabetic patients were also subjected for urine protein investigation by gel electrophoresis and the immunoelectrophoresis. The obtained results were correlated with age, disease duration, sex and treatment type. In patients with diabetes for less than 5 years and proteinuria not more than 100 mg/dl, albumin, transferrin and ceruloplasmin were the protein components mostly excreted in urine and the proteinuria in such cases was described as selective. In patients with diabetes of more than 5 years and proteinuria exceeding 100 mg/dl, additional relatively high molecular weight proteins including IgA and IgG were detected and the proteinuria in such cases can be considered as non selective.

From the previous results, it can be concluded that, selective proteinuria was encountered in young males as well as the same number of young females at the same age, whereas the non-selective proteinuria seems to be of higher frequency among adult females than adult males, and it can be considered as a sign of advanced nephritic status that would require much more intensive medical care.

CONTENTS

ABSTRACT PAGE

I CHAPTER I

INTRODUCTION AND AIM OF WORK 1

LITERATURE REVIEW 3

I-1 DIABETES MELLITUS 3

I-1.1 Definition 3

I-1.2 Origin of diabetes 4

I-1.3 Classification of diabetes 4

I-1.4 Diabetes symptoms 9

I-1.5 Cause of diabetes 10

I-1.6 The complications of diabetes mellitus 11

I-1.7 The pancreas functions 17

I-1.8 The liver functions 18

I-1.8.1 The role of the liver in glucose homeostasis 18 I-1.9 Lipid components in diabetes patients 21

I-1.9.1 Serum total lipids 21

I-1.9.2 Serum triglycerides 22

I-1.9.3 Lipase and amylase 23

I-1.9.4 Serum free fatty acids 24

I-1.9.5 Serum total cholesterol 25

I-1.9.6 Serum phospholipids 26

I-1.10 Diabetic nephropathy 27

I-1.10.1 Clinical significance of proteinuria in diabetes 27 I-1.10.2 Characteristics of diabetic patients with various degree of

renal involvement

30

II CHAPTER II

II.1 MATERIALS AND METHODS 32

A

32

II-1.1 MATERIALS 32

II-2.1 METHODS 32

II-2.1.1 Determination of blood glucose, liver, kidney and pancreatic function tests in different diabetic Patients (IDDM and NIDDM) with and Without ketosis.

33

B Investigation of serum total lipids and Lipid components 34

II-1.2 MATERIALS 34

II-2.2 Determination of serum total lipids 36 II-2.3 Determination of serum total cholesterol 37 II-2.4 Determination of serum phospholipids 37 II-2.5 Determination of serum triglycerides 38 II-2.6 Determination of serum free fatty acids 38 C Investigation of urinary proteins in diabetic patients 39

II-3 MATERIALS 39

II-2.3 METHODS 40

II-2.3.1 Determination of urine total protein, and protein compounds 40

II.4 Statistical analysis 40

III CHAPTER III

III-1 RESULTS 41

III-1.1 Determination of kidney, liver, and pancreatic function tests in different diabetic Patients (IDDM and NIDDM) with and without ketosis.

41 III-2 Determination of total lipids and lipids components in

diabetic patients

58

III-2-1 Serum total lipids 58

III-2-2 Serum cholesterol 59

III-2-3 serum phospholipids 60

III-2-4 serum triglycerides 61

III-2-5 serum free fatty acids 62

III-3 Determination of urinary protein and diabetic patient's nephropathy in diabetic patients.

80

IV CHAPTER IV

DISCUSSION 96

RECOMMENDATION 110

REFERENCES 111

APPENDIX --

ARABIC SUMMARY --

ABBREVIATIONS

A/G AER Alb ALP ALT AST Apo ATP CAD cAMP DM ESRD FFA GDM G-Hb GFR GOT GPT

HMG- CoA HNKS HLA HbA1c HDL LDL LCAT LPL

Albumin/Globulin Albumin Excretion Rate Albumin

Alkaline Phosphatase Alanine Transferase Aspartate Transaminase Apoprotein

Adenosine Triphosphate Coronary Artery Disease

cyclic Adenosine Monophosphate Diabetes Mellitus

End Stage Renal Disease Free Fatty Acids

Gestational Diabetes Mellitus Glycolated Heamoglobin Glomerular Filtration Rate glutamic oxalic transaminase glutamic pyruvic transaminase

3-Hydroxy- 3- Methylglutaryl- Coenzyme A Hyperosmolar NonKetotic Syndrome

Human Leukocyte Antigens Human Hemoglobin

High Density Lipoprotein Low Density Lipoprotein

Lecithin Cholesterol Acyltransferase Lipoprotein Lipase

IDDM MODY NDDG NIDDM NIDDM- I NADPH n.s O.D P PL p.m SD S.S TC TL T.P UAER v.h.s VLDL W/V WHO

Insulin Dependent Diabetes Mellitus Maturity-Onset Diabetes of the young National DiabetesData Group

Non- Insulin Dependent Diabetes Mellitus

Non- Insulin Dependent Diabetes Mellitus - Insulin Treated Nicotinamide Adenine Dinecliotide Phosphate

non significance Optical Density

Degree of probability Phospholipids

past meridian Standard Deviation Slightly significant Total Cholesterol Total Lipid Total Protein

Urinary Albumin Excretion Rate very high significant

Very Low Density Lipoprotein Weight / Volume

World Health Organization

CHAPTER I

LETERATURE REVIEW

INTRDUCTION AND AIM OF THE WORK

Diabetes mellitus is a common metabolic disorder affecting the metabolism of carbohydrates, lipids, proteins and enzyme activities. The present study deals with investigations on liver and pancreatic function tests for serum aspartate, alanine amino transferase, alkaline phosphatase, total lipase and amylase enzymes.

Kidney function tests were also assessed for blood urea and serum creatinine, serum total proteins and protein fractions were also studied. In addition, the correlation of such finding with age, sex, ketotic state & diabetics (type 1 & type 2) have been studied. Although many biochemical parameters are now available investigating of diabetic patients with pancreatic disease, a single use of one of them was found unsatisfactory.

The actual work, therefore, has been divided into 3 main parts, each has been studied separately.

Part 1 concerns the liver, kidney and pancreatic functions for the following purposes:

-To determine if any complication related to the pancreas, liver and kidney function tests if it can be changed or not in diabetic patients with or without ketonuria.

-Also, if it can be possible that diabetic patients with ketosis may show or not any evidence of pancreatitis in juvenile or adult diabetic patients.

For this reasons, 60 cases (28 males + 32 females) divided into three groups were studied: Thus, juvenile group as well as two other groups of adult diabetic patients associated with ketotic or non-ketotic condition were selected and investigated.

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Part 2 investigates the controversy observed among the data reported by many authors, due to diverse number of factors among which are race, environmental, socio-economic, age, sex differences, mode of treatment and the case level, a great interest in this study is also focused on changes and abnormalities in lipid metabolism. Such abnormalities may lead generally to undesirable complications following diabetes mellitus.

For this reasons, other 85 diabetic patients (45 males + 40 females) with or without ketosis as compared to 38 control subjects were also studied.

All diabetic patients were divided into other different groups according to variable mode of classification. In addition, since, nephropathy is the most common and serious complication accompanying the diabetic patients.

Part 3 is concerned to the classification of the type and molecular weight of either heavy or light protein components, and its nature, whether selective or non selective in relation to age, duration, sex, and type of treatment.

For this reasons, the urine of 115 diabetic patients of 28 juveniles (14 males + 14 females) and 87 adults (56 females + 31 males) were analyzed.

I-1. DIABETES MELLITUS

I-1.1. Difinition:

Diabetes mellitus is one of the most common endocrine diseases, associated with a group of metabolic disorder characterized by chronic hyperglycemia with disturbances of carbohydrate, lipids, and protein metabolism resulting from defects in insulin secretion, insulin action, or both (Taylor, 1999). The effect of diabete mellitus include long-term damage, dysfunction, and failureof various organs, especially the eyes, kidneys, nerves, heart,and blood vessels (Zimmet and Alberti, 1998).

Greek and Roman physician used the term "diabetes" to refer to conditions in which the cardinal finding was a large urine volume, and 2 types were distinguished "diabetes mellitus" in which the urine lasted sweet and "diabetes insipidus" in which the urine was tasteless. Today the term diabetes insipidus is reserved for the action by deficiency of antidiuretic hormone from the posterior pituitary gland and the unmodified word diabetes is generally used as a synonym for diabetes mellitus (Ganong, 1983).

Diabetes is not a single disease but a heterogeneous group of disorders in cause and type (Fajans et al., 1978). Heterogeneity of diabetes implies that there are differences among various groups of patients in terms of etiology.

Pathogenesis (genetic, environmental and immune factors, in natural history and in response to treatment. The disease may be found in a variety of clinical presentations, ranging from asymptomatic states in patients with mild insulin deficiency to debilitating conditions of weight loss, thirst polyuria, dehydration and coma in those with severe insulin deprivation (Fajans, 1989; Owen &

Shuman, 1990).

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Diabetes is a disease of global distribution, affecting individuals of all ages with widely varying prevalence rates in different populations and within the same population. Epidemiologic studies have shown an increased frequency related to changes in life-style, urbanization, dietary changes, obesity and stress are putative factors in this propensity for glucose intolerance and diabetes mellitus in a certain population (Owen & Shuman, 1990).

I-1.2. Origin of Diabetes:

Diabete comes from a Greek word that means to siphon or "passing though,". The most obvious sign of diabetes is excessive urination. Water passes through the body of a person with diabetes as if it were being siphoned from the mouth through the urinary system out of the body.

Mellitus comes from a Latin word that means sweet like honey. The urine of a person with diabetes contains extra sugar (glucose).

In 1679, a physician tasted the urine of a person with diabetes and described it as sweet like honey.This had been noticed long before in ancient times by the Greeks, Chinese, Egyptians, and Indians.

In 1776 Matthew Dobson confirmed the sweet taste was because of an excess of a kind of sugar in the urine and blood of people with diabetes (Dobson, 1776).

I-1.3. Classification of Diabetes

According to the classification recommended by the (American Diabetes Association, 2004), diabetes mellitus can be classified as type 1, type 2, other specific types, and gestational diabetes mellitus as shown intable (1).

Table 1: Etiologic Classification of Diabetes Mellitus

I. Type 1 diabetes* (β-cell destruction, usually leading to absolute insulin deficiency)

1. Immune mediated 2. Idiopathic

II. Type 2 diabetes* (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance)

III. Other specific types

1. Genetic defects of b-cell function 2. Genetic defects in insulin action 3. Diseases of the exocrine pancreas 4. Endocrinopathies:

1. Acromegaly

2. Cushing's syndrome 3. Glucagonoma 4. Hyperthyrodism 5. Somatostatinoma 6. Aldosteronoma 5. Drug- or chemical-induced 6. Infections

1. Congenital rubella 2. Cytomegalovirus 3. Others

7. Uncommon forms of immune-mediated diabetes 1. "Stiff-man" syndrome

2. Anti-insulin receptor antibodies 3. Others

8. Other genetic syndromes sometimes associated with diabetes 1. Down's syndrome

2. Klinefelter's syndrome 3. Turner's syndrome

IV. Gestational diabetes-mellitus (GDM)

*Patients with any form of diabetes may require insulin treatment at some stage of their disease. Such use of insulin does not, of itself, classify the patient.

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I-1.3.1. Type 1 Diabetes Mellitus:

Formerly known as insulin-dependent diabetes mellitus (IDDM), childhood diabetes, this type of diabetes can affect children or adults but was traditionally termed "juvenile diabetes" because it represents a majority of cases of diabetes affecting children and young adults and accounts for approximately 15% of the total diabetic population (Owen and Shaman, 1990). About 40% of people with type 1 develop severe nephropathy and kidney failure by the age of 50. It is characterized by the development of ketoacidosis in the absence of insulin therapy or insulin deficiency caused by autoimmune or idiopathic destruction of pancreatic β-cells (Atkinson and Maclaren, 1994), abrupt onset of symptoms and absolute dependence on exogenous insulin not only to control the hyperglycemia but to prevent the occurrence of ketoacidosis and sustain life (American Diabetes Association, 2004).

Type 1 diabetes is thought to be inherited in genetically susceptible individuals by environmental factors such as viral, toxic or chemical agents that lead to autoimmune destruction of β-cells, resulting in the formation of altered protein components. This material is a foreign antigen to the immuno system, establishing the basis for an autoimmuno reaction against the cell of origin the β-cell (Goruch et al., 1983 and Bosi, 1987).

I-1.3.2. Type 2 Diabetes Mellitus :

Previously known as non-insulin dependent diabetes mellitus (NIDDM), adult-onset diabetes mellitus, maturity- onset diabetes mellitus, accounts for more than 90% of all diabetes with unknown specific etiology, but hereditary factors, aging, and obesity are important risk factors (American Diabetes Association, 2004). Two groups of patients with NIDDM were recognized by different body composition, obese and no obese. In addition, a third group called maturity-onset diabetes of the young (MODY) had been described for those individuals in whom the diagnosis of diabetes is made before the age of 25

years. With the disease being non-ketosis rarely leads to ketoacidosis and typically response to diet and/or sulfonylurea urea drugs (Fajans, 1989).

Type 2 diabetes is usually associated with a positive family history, and begins in middle life or beyond, often over the age of 40. Symptoms being more gradually than in IDDM, and the diagnosis is frequently discovered when an asymptomatic person is found to have elevated plasma glucose on routine laboratory examination. In contrast to insulin-dependent disease, plasma insulin levels are normal to high although there are an inability of insulin to lower plasma glucose levels effectively an-abnormality termed insulin resistance.

Type 2 diabetes can result from genetics defects that cause both insulin deficiency and insulin resistance (a term refers to impaired tissue response to insulin) occurs during the early phase of NIDDM, but the disease frequently goes undiagnosed for many years because hyperglycemia during the earlier stages is not severe enough to cause symptoms (Foster., 1994, American Diabetes Association, 2004).

The pathophysiologic alterations in type 2 diabetes include abnormal insulin secretion and resistance to insulin action in target tissues. Although either defects may be the initial pathogenic event that ultimately leads to the disease, most patients with the fully developed syndrome show impairments of both insulin secretion and insulin-mediated glucose disposal (insulin or insulin antibodies) receptors (decreased number or diminished binding of insulin) or post receptor (Abnormal signal transduction especially failure to activate tyrosine kinase) abnormalities. Obesity is the most common cause of insulin resistance (DeFronzo et al., 1992 and Sherwin, 1996). The comparison between type 1 and type 2 is showed in table 1.

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Table (1): Comparison between IDDM and NIDDM.

Type I (IDDM) Type II (NIDDM)

Age at onset Usually under 40 Usually over 40

Body weight Thin Usually overweight

Symptoms Appear suddenly Appear slowly Insulin

produced

None Too little, or it is ineffective Insulin

required

Must take insulin May require insulin (20-30%) Other names Juvenile diabetes Adult onset diabetes

Symptoms

Usually abrupt, thirst, polyuria, polyphagia, weight loss

Frequently asymptomatic or thirst, fatigue visual blurring and easy fatigability

Nutritional status

Usually nonobese 60-80% obese

Etiology

virus or other

environmental factors

Family history and strong association with obesity.

Pathogenesis

Chronic autoimmunity against islet β-cells; islet cell antibodies detected years before clinical onset

Impaired insulin secretion and/or insulin resistance.

Endogenous insulin and C-peptide level

Negligible to absent Normal or higher levels, but low in relation to blood sugar Acute

complication

Diabetic ketoacidosis Hyperosmolar state: ketosis, rarely with infection or stress.

Sulfonylurea No response Effective for majority

Diet Mandatory Mandatory: diet alone may

control blood sugar.

I-1.4. Symptoms of Diabetes:

Usually, the symptoms of type 1 diabetes are obvious. That is not true for type 2. Many people with type 2 do not discover they have diabetes until they are treated for a complication such as heart disease, blood vessel disease (atherosclerosis), stroke, blindness, skin ulcers, kidney problems, nerve trouble or impotence. The warning signs and symptoms for both types are:

Type 1: Frequent urination, increased thirst, extreme hunger, unexplained weight loss, extreme fatigue, blurred vision, irritability, nausea and vomiting.

Type 2: Any type 1 symptom, plus: unexplained weight gain, pain, cramping, tingling or numbness in your feet, unusual drowsiness, frequent vaginal or skin infections, dry, itchy skin and slow healing sores.

If a person is experiencing these symptoms, they should see a doctor immediately (The HealthScoud Network Contact US, 2001-2007)

• Frequent urination (even at night) (polyuria)

• Excessive thirst (polydispia)

• Always being very hungry (polyphagia).

• Dry skin

• Itchy skin

• Slow healing of cuts

• Blurry eyesight

• Feeling tired and weak

• Weight loss

• Skin infections

• Numbness or tingling in feet

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I-1.5. Causes of Diabetes:

Many factors, especially heredity and obesity are important in the development of diabetes (The HealthScoud Network Contact US, 2001-2007):

Heredity: family history of diabetes. If you have a parent, grand parent, brother, or sister who has diabetes, you are more likely to develop diabetes. There is about a 5% risk of developing type 2 diabetes if your mother, father, or sibling has diabetes. There is a higher risk (up to 50%) of developing type 2 diabetes if your parent or siblings have type 2 diabetes and you are overweight.

Obesity: 80% of people with type 2 diabetes are overweight when diagnosed.

Diabetes symptoms disappear in many of these obese patients when they lose weight.

Age: Advanced age cause improper functioning of the pancreas.

Viruses: Certain viruses may destroy β-cells in susceptible people.

Faulty immune system: There is not cause of diabetes, but multiple factors that may trigger the immune system to destroy β-cells.

Physical trauma: An accident or injury may destroy the pancreas, where insulin is normally produced.

Drugs: Drugs prescribed for another condition may unmask diabetes.

(Medication cortisone and some high blood pressure drugs).

Stress: Hormones released during periods of stress may block the effect of insulin.

Pregnancy: Hormones produced during pregnancy may block the effect of insulin.

Unhealthy diet: Bad diet can cause diabetes.

I-1.6. The complications of diabetes mellitus:

The complications are far less common and less severe in people who have well-controlled blood sugar levels, (Nathan et al., 2005)^. In fact, the better the control, the lower the risk of complications. Hence patient education, understanding and participation are vital. Healthcare professionals who treat diabetes also address other health problems that may accelerate the deleterious effects of diabetes. These include smoking (abstain), elevated cholesterol levels (control with diet, exercise or medication), obesity (even modest weight loss can be beneficial), high blood pressure, and lack of regular exercise (Ann Intern Med, 1995).

I-1.6.1. Acute complication of diabetes mellitus:

The acute complications of diabetes are a direct result of abnormalities in the plasma level: Hyperglycemia or hypoglycemia. Initial symptoms of

hyperglycemia are increased urination (Polyuria), fatigue or blurry vision. If uncorrected, hyperglycemia eventually may lead to diabetic ketoacidosis (DKA) or non-ketotic hyperosmolar coma. In actually, they represent parts of a spectrum of a disease process characterized by varying degrees of insulin deficiency over production of counter regulatory hormones and dehydration hypoglycemia, another acute complication of diabetes, results from an imbalance between the medication for diabetes treatment (insulin or sulfonylurea) and the patient's food intake or exercise. Because the brain depends almost entirely on glucose can lead to confusion, stupor or coma (Clement and Torrens, 1995).

I-1.6.1.1. Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute, dangerous complication and is always a medical emergency. On presentation at hospital, the patient in DKA is typically dehydrated and breathing both fast and deeply. Abdominal pain is

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common and may be severe (Susan a nd Kecokes, 1993).The level of consciousness is normal until late in the process, when lethargy (dulled or reduced level of alertness or consciousness) may progress to coma. The ketoacidosis can become severe enough to cause hypotension and shock. Prompt proper treatment usually results in full recovery, though death can result from inadequate treatment, delayed treatment or from a variety of complications. It is much more common in type 1 diabetes than type 2, but can still occur in patients with type 2 diabetes (Williams, 1996).

I-1.6.1.2. Non ketotic hyperosmolar coma :

While not always progressing to coma, this hyperosmolar non-ketotic state (HNS) is another acute problem associated with diabetes mellitus. It has many symptoms in common with DKA, but a different cause, and requires different treatment. In anyone with very high blood glucose levels (usually considered to be above 300 mg/dl or 16 mmol/l), water will be cosmetically driven out of cells into the blood. The kidneys will also be "dumping" glucose into the urine, resulting in concomitant loss of water, causing an increase in blood osmolality. If the fluid is not replaced (by mouth or intravenously), the osmotic effect of high glucose levels combined with the loss of water will eventually result in such a high serum osmolality (dehydration). The body's cells may become progressively dehydrated as water is drawn out from them and excreted. Electrolyte imbalances are also common. This combination of changes, especially if prolonged, will result in symptoms of lethargy (dulled or reduced level of alertness or consciousness) and may progress to coma. As with DKA urgent medical treatment is necessary, especially volume replacement.

This is the diabetic coma which more commonly occurs in type 2 diabetics.

Coma in diabetes can be due to acidosis and dehydration. However, the blood glucose can be elevated to such a degree that independent of plasma pH, the hyperosmolarity (hyperosmolarcoma) of the plasma causes unconsciousness.

Accumulation of lactic acid in the blood (lactic acidosis) may also complicate diabetic ketoacidosis if the tissues become hypoxic and lactic acidosis may itself cause coma (Ganong, 1983).

I-1.6.1.3. Hypoglycemia

Hypoglycemia, or abnormally low blood glucose, is a complication of several diabetes treatments. It may develop if the glucose intake does not match the treatment. The patient may become agitated, sweaty, and have many symptoms of sympathetic activation of the autonomic nervous system resulting in feelings similar to dread and immobilized panic. Consciousness can be altered, or even lost, in extreme cases, leading to coma and/or seizures or even brain damage and death. In patients with diabetes this can be caused by several factors, such as too much or incorrectly timed insulin, too much exercise or incorrectly timed exercise (which decreases insulin requirements) or not enough food or insufficient amount of carbohydrates in food. In most cases, hypoglycemia is treated with sweet drinks or food. In severe cases, an injection of glucagon (a hormone with the opposite effects of insulin) or an intravenous infusion of glucose is used for treatment, but usually only if the person is unconscious. (Taylor, 1999).

I-1.6.2. Chronic complications of diabetes mellitus

The most patients with diabetes are susceptible to an extensive array of medical complications; most of the problems can be attributed to particular susceptibility to damage to the eye (retinopathy), the kidney (nephropathy), the peripheral nerves (neuropathy), and the blood vessels (atherosclerosis). The first three categories of complication are relatively specific for diabetes and are characterized by pathologic endothelial changes, such as basement membrane thickening and increased vascular permeability. For this reason, retinopathy, nephropathy and neuropathy have been categorized as microvascular

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complications of diabetes. The increased susceptibility to atherosclerosis and its complications are categorized as macro vascular complications (Clement, 1995).

The functional and structural changes in the involved organs usually lead in turn to the development of well-defined clinical entities, the so-called

"complications of diabetes", which most characteristically affect the eye, the kidney and the nervous system (Reginald et al., 1975) suggest that, the term

"complication" may be rejected, arguing that the tissue changes are an integral part of a "syndrome", preceding or even initiating hyperglycemia. However, the complications of diabetes can be categorized into vascular complications (arteriosclerosis, eyes and kidneys), infections (there is lowering resistance towards infection especially if the diabetes is poorly-controlled) (George and Cahill, 1985), and coma (Ketoacidosis and non-ketoacidosis).

The disease occurs when insulin activity (not necessarily the amount of pancreatic insulin secretion) is deficient. Since the introduction of insulin for diabetic therapy and the subsequent increased longevity of diabetics, the vascular complications of diabetes have appeared as a major cause of morbidity (Beach et al., 1979 and Tunbridge, 1981). Vascular complications can be divided into two types; affecting glomeruli and arteriosclerosis involving the cranial arteries, coronary arteries and peripheral arteries (Platon et al., 1978).

Involvements of the peripheral arteries frequently lead to claudication, ischemic ulcers and amputation (Strandness et al., 1964). In fact, it is generally accepted that, arteriosclerosis spears at an earlier age in diabetics, is more extensive and is associated with a higher morbidity and mortality (Santen et al., 1972; West, 1978 and Tunbridge, 1981).

I-1.6.2.1. Microvasclar disease

Chronic elevation of blood glucose level leads to damage of blood vessels.

In diabetes, the resultant problems are grouped under "microvascular disease"

(due to damage to small blood vessels) and "macrovascular disease" (due to

damage to the arteries).The damage to small blood vessels leads to a microangiopathy, which causes the following organ-related problems:Diabetic retinopathy, growth of friable and poor-quality new blood vessels in the retina as well as macular edema (swelling of the macula), which can lead to severe vision loss or blindness. Retinal damage (from microangiopathy) makes it the most common cause of blindness among non-elderly adults in the US.

• Diabetic neuropathy, abnormal and decreased sensation, usually in a stocking distribution starting at the feet but potentially in other nerves.

When combined with damaged blood vessels this can lead to diabetic foot (see below). Other forms of diabetic neuropathy may present as mononeuritis or autonomic neuropathy.

• Diabetic nephropathy, damage to the kidney which can lead to chronic renal failure, eventually requiring dialysis. Diabetes mellitus is the most common cause of adult kidney failure worldwide.

• Diabetic nephropathy develops in close to 40% of patients with type 1 diabetes and in 5% to 40% of patients with type 2 diabetes. Genetics play an important role: Patients who have one or two deletions of the angiotensin-converting enzyme (ACE) gene, a defect in the sodium proton pump, or a family history of hypertension are at increased risk for progression to diabetic nephropathy (Parving et al., 1996). However, in such patients, nephropathy does not occur until type 1 diabetes develops;

the worse and more prolonged the hyperglycemia, the greater the risk of diabetic nephropathy (Parving et al., 1996).

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I-1.6.2.2. Macrovascular disease:

Macrovascular disease leads to cardiovascular disease, mainly by accelerating atherosclerosis:

• Coronary artery disease, leading to myocardial infarction ("heart attack")

• Peripheral vascular disease, which contributes to intermittent claudication (exertion-related foot pain) as well as diabetic foot.

• Diabetic myonecrosis

Diabetic foot, often due to a combination of neuropathy and arterial disease, may cause skin ulcer and infection and, in serious cases, necrosis and gangrene. It is the most common cause of adult amputation, usually of toes and or feet, in the US and other Western countries. However, diabetes does cause higher morbidity, mortality and operative risks with these conditions (Weiss and Sumpio, 2006).

I-1.7. The Pancreas functions:

The pancreas is a small organ located in the abdomen, behind the stomach. It is attached to the small intestine and the spleen. Inside the pancreas are small clusters of cells called "the islets of Langerhans". The islets of Langerhans are endocrine tissue containing four types of cells. In order of abundance, they are:

• Beta cells, which secrete insulin and amylin.

• Alpha cells, which secrete glucagons.

• Delta cells, which secrete somatostatin.

• Gamma cells, which secrete a polypeptide of unknown function.

Within the islets are β-cells, which produce insulin it is stored within vacuoles pending release, via exocytosis, which is triggered by increased blood glucose levels. β-cells have channels in their plasma membrane that serve as glucose detectors. Insulin is the principal hormone for maintaining glucose homeostasis and regulating carbohydrate, lipid, and protein metabolism by suppressing gluconeogenesis and glycogenolysis in the liver and by stimulating the uptake of glucose into skeletal muscle and fat (Saltiel a nd Kahn, 2001).

Insulin is a polypeptide hormone composed of 51 amino acid residues an alpha chain called the A chain of 21 amino acids linked by two disulfide (S-S) bridges to a beta chain called the B chain of 30 amino acids, and has a molecular weight of 5808 Da. Insulin exerts its physiological actions by binding to its receptor on cell membrane (Massague et al, 1980).

In people who do not have diabetes, glucose in the blood stimulates production of insulin in the β-cells. β-cells "measure" blood glucose levels constantly and deliver the required amount of insulin to funnel glucose into cells. They keep blood sugar in the normal range of 60 mg to 120 mg. When there is little or no insulin in the body, or when insulin is not working properly,

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glucose has difficulty entering your cells. Also, when there is not enough insulin, excess cannot be stored in the liver and muscle tissue. Instead, glucose accumulates in your blood. This high concentration of glucose in the blood is called hyperglycemia or high blood sugar (Taylor, 1999).

I-1.8. The liver functions:

The human liver performs multiple functions essential for life. The liver directly receives processes and stores materials absorbed from the digestive tract such as amino acids, carbohydrates, fatty acids, cholesterol and vitamins and is capable of releasing metabolites of these compounds on demand. The liver synthesize multiple plasma proteins including albumin, α-globulin, β-globulin, blotting and transport proteins. These factors influence homeostasis, since binding proteins modulate the circulating total concentrations of calcium, magnesium and many drugs, while albumin concentrations regulate the plasma oncotic pressure and thus influence the dynamics between the blood and the tissues (Balistreri & Rej, 1994).

The liver responds to multiple hormonal and neutral stimuli to regulate the blood glucose concentration and contributes to the body is immune system (Whicher, 1983 and El-Shebl, 1993).

I-1.8.1. The role of the liver in glucose homeostasis:

The liver has a central role in glucose homeostasis (DeFranzo and Ferrannini, 1987). In the post absorptive, fasting state and basal hepatic glucose production is in precise equilibrium with basal glucose utilization by the brain and other tissue that are obligate glucose consumers. The liver release both from glycogen stores (glucogenolysis) and from newly synthesized glucose (gluconeogenesis).In control the postprandial state, substrate-related meremental Insulin secretion stimulates glucose utilization and storage, while inhibiting hepatic glucose output. The liver also responds to hypoglycemia by providing

glucose acutely. This mediated by three distinct pathways (Moore &

Cherrington, 1996).

1- The action of epinephrine on the liver.

2- The action of glucagon on the liver.

3- The direct innervations of the liver.

The metabolic rate of ingested glucose within the liver appears to involve the removal of about 30% to 40% of the glucose that enters the portal vein following an oral glucose load. The liver replete its glycogen stores by both direct and indirect pathways (Shulman et al., 1990). The regulation of hepatic glucose uptake involves a complex interaction of neural and hormonal mechanisms. Insulin and glucagons levels, the amount of glucose presented to the liver, and the portal neural signal are important regulators of the liver's response to glucose delivery (Moore and Cherrington, 1996).

Insulin increases hepatic glucose uptake and suppresses hepatic glucose production (Bergman, 1977). On contrast, glucagons reduces net hepatic glucose uptake during portal glucose delivery due to lack of suppression of endogenous glucose production. Whereas, insulin activities glycogen syntheses and increases glycogen deposition, glucagons reduces glycogen synthesis activity and glycogen deposition. In addition to this, epinephrine alters hepatic glucose production. A physiologic increment in plasma epinephrine increases hepatic glucose production by increasing both the maximal gluconeogenic rate and glycogenolysis, with gluconeogenesis being responsible for 60% of the overall increase in glucose production.

In contrast, intraportal epinephrine, which elevates sinusoidal glucose levels? Increases hepatic glucose production but does not change the maximal gluconeogenic rate, thus its effect on glucose production is attributable solely to an increase in glycogenolysis (Marks and Skyler, 1999). Moore and Cherrington, (1996) reported that the neutral of hepatic glucose metabolism

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includes a tonic block of glucose entry into the liver, probably mediated by both sympathetic neural activity and low insulin: glucagons ratio. An increase in the portal vein glucose level is detected by portal region sensors that cause a decrease in the firing rate of the hepatic branch of the vagus nerve.

The change in the afferent firing rate is processed in the hypothalamus and instigates a change in the efferent firing rate of the hepatic and pancreatic branches of the vagus, with corresponding increases in insulin secretion and net hepatic glucose uptake. The portal signal not only serves to direct glucose into the liver but also appears to stimulate its deposition as glycogen. A saturable pathway of insulin degradation is located in the liver. Most insulin is metabolized by this way, and 50% of secreted insulin is extracted on the first pass through the liver (Marchesini et al., 1990). The metabolic disturbances, which involve the liver, have been recently reviewed (Stone & Van Theil, 1985 and Fagivoli and Van Theil, 1993).

In type I diabetes, resulting from insulin lack, the liver contributes to the disturbances in carbohydrate metabolism. The hyperglycemia results from breakdown of glycogen and over-production of glucose by the liver together with a decreased uptake of glucose from the portal vein blood. The activity of glucose-6-phosphatase is increased with resulting increased glycogenolysis and decreased phosphorylation in the liver. Over-production of glucose also occurs due to a loss of the normal feedback inhibition of gluconeogenesis by plasma glucose levels (Wahren et al., 1972). The uptake of glucose from portal vein blood is considerably reduced (Felig, 1977).

I-1.9 Lipid components in diabetic patients:

I-1.9.1 Serum Total Lipids:

Lipids are important dietary constituents, not only for their high energy value, but also because of the fat-soluble vitamins and essential fatty acids contained in the fat of natural foods. Lipid metabolic abnormalities play an important role in various diseases such as hyperlipidemia, heart disease and diabetes mellitus (Felts and Rudel, 1975), (Gurr and James, 1975) and (Liebich, 1986). Diabetes and hyperlipidemia are frequently associated pathologic states. Diabetes is considered causative or aggravating factors in hyperlipidemia. Yet, the incidence of hyperlipidemia is high in this state, and the severity of disturbed metabolism differs from one patient to another (Debry et al., 1979). Hyperlipidemia is the result of an imbalance between the formation and degradation of either the lipoprotein entity or any of its constituents. The level of serum lipids are affected by a multitude of factors such as race, heredity, age, sex, hormones, diet, physical activity, season and method of analysis (Larsson et al., 1962).

Few of the materials in the literature are uniform in these respects and any detailed comparison between the results of different investigators would therefore be of limited value. Of interest to mention, is that serum lipids are different among population of different countries. Thus in diabetics Senegalese, serum lipids and its components were increased in relation to that of healthy Senegalese, who show lower or less have the same levels as healthy Europeans (Josselin, et al., 1976). The most common lipid abnormality in diabetic is hyperglycerdemia (Bagdade et al., 1968), but plasma cholesterol also can be increased. In addition, the chemical composition of lipoproteins is abnormal (Schonfeld et al., 1974).

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I- 9.1.2 Serum triglycerides :

Triglycerides are stored in adipose and act as a large energy reserve, which can be made available when required by enzymatic hydrolysis to fatty acids and glycerol. About 30-40% of people's daily caloric intake is normally in the form of fat. After hydrolysis, the dietary fat is absorbed primarily monoglycerides and fatty acids, and resynthesized into triglycerides in the mucosal cells. The triglycerides are then combined with cholesterol, phospholipids and apolipoprotein and secreted into the lymph system as chylomicrons. The amount of fat is a meal appears to determine the amount of triglycerides resyntheslized in the mucosal cells, the more the latter, the higher and the proportional of chylomicrons to VLDL (Gangl and Ockner, 1975).

It has been established that diabetes is often associated with increased plasma triglyceride level and (Laakso et al., 1985; 1987).

In insulin- dependent diabetes mellitus (Juvenile-onset diabetes), the change in both males and females was insignificant (Beach et al., 1979).

Serum triglyceride level was significantly higher in alloxan-diabetic rabbits than in non-diabetic rabbits (Kantardzhyan, 1976) and in young alloxan- diabetic rats than in non-diabetic rats (Saatov et aI., 1980).

Multiple mechanisms may be responsible for the increase of serum trigly- ceride level in diabetes. In absolute insulin-deficiency, there is an increased concentration of serum free acids with increased endogenous synthesis of triglycerides (Nikkila and Kekki, 1973) and a decreased activity of adipose tissue lipoprotein lipase and post heparin lipoprotein lipase (Bagdade et aI., 1968), which provide an adequate explanation for hypertriglyceridemia.

I-1.9.3 Lipase and amylase enzymes :

Lipase and amylase are two digestive enzymes produced by the pancreas that can be measured in the blood (Miura et al., 2002). The pancreas has two separate functions: the endocrine function of blood glucose regulation and the exocrine function of digestion. When either of these functions is abnormal, it may cause the other one to be disrupted. Diabetes can cause pancreatitis and pancreatitis can cause diabetes. In pancreatitis, where the inflammation occurs suddenly or gradually over a long period of time, acute pancreatitis causes little or no permanent damage to the pancreas, while chronic pancreatitis can result in scar tissue forming in the pancreas, which in turn decreases the ability of the pancreas to function properly.

It is concluded that the serum activity of pancreatic enzymes increases with the degree of diabetic disequilibrium and mainly correlate with metabolic factors such as hyperglycemia, dehydration and acidosis. Amylase inhibition has gastrointestinal and metabolic effects that may aid in the treatment of diabetes and obesity or type 2 diabetes mellitus (Lankisch et al., 1998). So, the pancreatic enzymes might be of value in determining the severity and chronicity of human insulin-dependent diabetes, and can be used as a parameter in evaluating the response to treatment (Aughsteen and Mohammed, 2002).

Yadav, et al., (2000), found that the estimation of amylase and lipase enzymes are the standard testes to diagnose acute pancreatitis (AP). The aim of their studies was to evaluate the incidence and magnitude of non specific elevations of amylase and lipase in diabetic ketoacidosis (DKA). In DKA nonspecific elevations of amylase and lipase occurred in 16-25% of the cases.

Amylase and lipase elevation are correlated with serum osmorality.

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I-1.9.4 Serum free fatty acids (SFFA):

The so-called free fatty acids do not, in fact, exist in the plasma in a free form but are always bound to albumin. Normally about 2-3 molecules of fatty acid are transported on each molecule of albumin and the complex so formed may be described as a special type of lipoprotein (Thomas a nd Gillham, 1989).

Fatty acids are present in plasma chiefly in esterified forms namely, triglycerides 45%, phospholipids 35%, cholesterol ester 15% and free fatty acids account for less than 5% of the total fatty acids present in plasma. The released fatty acids in adipose tissue can also reform triglycerides by uniting with α-glycerophosphate.

Since, the mammalian adipocyte lacks significant amounts of the enzyme glycerokinase to phosphorylate glycerol, a new source of α-glycerophosphate must be provided. Insulin provides this substrate by promoting the flux of glucose intra-cellular and the production via glycolysis of α-glycerophophate (Saudex and Eder, 1979).In diabetic subjects, it was found that serum FFA concentration was markedly increased than in non-diabetic subjects (Golay et aI., 1987). They also reported that, in diabetic children, the mean value of serum FFA was significantly higher than control and similarly, in adult-onset diabetic subjects, elevated serum FFA was observed by (Mingrone a nd Aldo, 1979).

Recently, significant relationship were seen between values for fasting plasma glucose and fasting serum FFA in non-insulin dependent diabetes mellitus (Fraze et aI., 1985; Golay et aI., 1987), and based upon these finding the possibility has been raised that the elevated serum FFA levels are the cause of the increase endogenous glucose production and resultant fasting hyperglycemia (Bogardus et aI., 1984).

I-1.9.5 Serum total cholesterol:

The normal human body contains about 2 gm of cholesterol per Kg.

total body weight, but only about 5% of this value is present in the plasma lipoproteins. Almost all animal tissues are capable of synthesizing cholesterol

from acetate, but the most activity synthesizing sites are the liver and gastrointestinal tract (Grundy, 1978). However, it was reported that, the mean level of serum cholesterol was significantly higher in normal girls than in normal boys in Washington and Sanghai (Zhijia et aI., 1986). These authors believed that cholesterol metabolism is influenced by hormones during the adolescent period. Serum cholesterol in Egyptian male normal children (6-12 years) was insignificantly higher than in corresponding females (Sabry et aI., 1983 b). However, (Wilding et aI., 1972) reported that in healthy subjects, serum cholesterol concentration is significantly higher in male than in female.

The mean value for serum cholesterol was found to be significantly increased with age (Hanz-hong et aI., 1986). An increase in blood cholesterol normally occurs after end of the adolescent period (Wilding et aI., 1972).

Several studies confirmed that plasma cholesterol is elevated in diabetic populations and there is evidence that other aspects of cholesterol metabolism are abnormal (Florey et aI., 1973). This may play a role in the accelerated development of the arteriosclerotic vascular disease that is a major long-term complication of diabetes in humans (Palumbo et aI., 1976). The concentration of serum cholesterol was increased in diabetic patients (Lowry and Barach, 1985). However, other authors, when compared between diabetic and non- diabetic subjects, found no difference in the concentration of serum cholesterol (Briones et aI., 1984; Taskinen et aI., 1986).

I-1.9.6 Serum phospholipids:

Phospholipids are complex lipids containing phosphate and a water soluble nitrogenous base. Phospholipids are widely distributed in all tissues and it is a major constituent of biological membranes. Bile phospholipids are important in keeping cholesterol in solution and lecithin is an-essential component of surfactant. Dietary phospholipids may be at least partially

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absorbed as such because of their relative solubility in water or they may be hydrolyzed before absorption, yet, plasma phospholipids are derived mainly from synthesis in the liver (Van-Deenen, 1971). Mayes, (1988b) reported that average serum phospholipids for healthy subjects were 215 mg/dl. In healthy Egyptian males (4-75 years) serum phospholipids were found to show significant increase with age (Abul-Fadl et aI., 1983). However, level of serum phospholipids was significantly higher in non-diabetic Sweden girls than in non-diabetic Sweden boys (Sterky et aI., 1963).

In diabetic patients, marked elevation of serum triglycerides and serum lipids is associated with a less pronounced increase of serum cholesterol and phospholipids (Spiro, 1972). In adequate diabetic control with insulin or hypoglycemic drugs was associated with a superimposed elevation of phospholipids level to normal value (George et aI., 1978). In alloxan-diabetic rats, the level of serum phospholipids was above that of normal rats and phospholipids / total cholesterol ratio was below that of normal rats (Uchida et aI., 1979; Saatov et aI., 1980).

I-1.10. Diabetic and nephropathy

Diabetic nephropathy is a major cause of death in diabetes mellitus, and is known to occur long time after clinical diabetes. For clinical proteinuria was taken as a marker for diabetic nephropathy. Standard tests for urine albumin excretion become positive around 100-150 microgram/min. The introduction of immunoelectrophoresis and other techniques to detect much smaller concentration of albumin in urine open a great knowledge diagnosis of diabetic renal disease. Microalbuminuria can be defined as abnormality elevated albumin excretion without clinical proteinuria such microalbuminuria is a good indicator of microvascular complication.

Proteinuria is the first manifestation of the syndrome owing to increased glomerular permeability. Later, progressive renal Failure is evidenced by increasing blood urea nitrogen and creatinine levels, none of the histopathologic changes observed in the kidney of diabetic patients is specific for diabetes mellitus. Typical lesions include widening of glomerular basement membrane, deposition of albumin and proteins in both and glomueruli and tubules, and accumulation of eosinophilic material in the glomerular tuft (Kimmelstiel- Wilson Nodules (Lavine, 1990).

I-1.10.1 Clinical significance of proteinuria in diabetes:

The proteinuria phase of diabetes mellitus may be characterized by its associated features, and these may also help define its clinical relevance (Mogensen, 1989). The abnormal albumin excretion is related both to the duration of diabetes and the degree of glycemic control. Renal function is usually well preserved with normal renal plasma flow, but early glomerular hyper filtration. Histological alteration particulary mesangial expansion and thickening of the glomerular basement membrane, may develop early and are

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often progressive, however, their expression may be dependent on the presence of concomitant hypertension.

Attention has also focused on two other major diabetic complications, retinopathy and neuropathy. Available data strongly suggest that both are related to the level of protein excretion including the micro albumin urine range (Parving et al., 1988). In an elegant study of albumin metabolism in type I diabetes abnormal movement or leakage of protein from the peripheral vasculature was present only in those patients with micro or macroalbuminuria – indicating extra renal vascular damage (Feldt, 1986).

Most of the microalbuminuria patients had developed overt nephropathy with decreased renal function. Albumin excretion is also a strong indicator for survival in NIDDM. When protein excretion is stratified according to the level of early morning urinary albumin concentration (normal <15 mg/L) and microalbuminuria (15-40 mg/l and 40-200 mg/l).

However , The presence and interactive effects of many of the conditions associated with microalbuminuria,e.g.,elevated blood pressure or overt hypertension , lipid and coagulation factor abnormalities , altered glomerular homodynamic and structural lesions , suggest that microalbuminuria could be an indicator of established , albeit early , nephropathy and generalized vascular disease , rather than a predictor of these complications (Deckert et al., 1989).

Microalbuminuria and clinical proteinuria are common features combined prevalence approximately 40% in NIDDM patients (Gall et al., 1991) and Nelson, 1988) but renal failure is a less prominent consequence than in insulin dependent diabetes mellitus (Mogensen, 1990). However, some factors are correlated with renal failure:

1- Plasma glucose:

Fasting plasma glucose in the factor most consistently and strongly associated with elevated urinary albumin levels in all analysis for both the total population and diabetic subjects alone. Similar findings have been reported by others for microalbuminuria and proteinuria (Schmitz and Veath, 1988) although a study found no association between albuminuria and level of glycemia and another found the association only in women (Gatting et al., 1988).

2- Blood pressure:

The importance of the association between elevated blood pressure and urinary albumin levels has been previously reported. Although other workers have reported similar results for NIDDM subjects with microalbuminuria (Gatting et al., 1988).

3- Duration of diabetes:

The duration of diabetes was not a significant independent correlate of either micro- or macroalbuminuria in Neurguan diabetic subjects. A study by (Suzuki et al., 1986), showed a relationship between urinary albumin excretion and disease duration in patients with IDDM but not with NIDDM, whereas other report found an independent association in women but not men with NIDDM (Mattok et al., 1988).

4- Obesity:

Indices of obesity were important independent correlates of elevated urinary albumin levels in all women and diabetic men and women with normal glucose tolerance. The link between obesity and hyperinsulinemia is well recognized and these results could suggest that association obesity and albuminuria might be mediated by insulin (Modan, 1986).